Long-Term Care Forms

Documentation of all asset transfers in the 60 months (5 years) before Medicaid application. Uncompensated transfers may result in a penalty period of Medicaid ineligibility.

Application for Medicaid coverage of nursing facility care. Includes detailed financial disclosure of income, assets, and transfers. A five-year look-back period for asset transfers applies.

Application for a qualified state LTC partnership insurance policy. Allows the policyholder to protect assets equal to benefits received when applying for Medicaid. Available in most states.

Standardized health status screening and assessment tool required for all residents of Medicare/Medicaid-certified nursing facilities. Used for care planning and Medicare payment calculation. Must be completed within 14 days of admission and periodically thereafter.

Medicaid long-term care admission notification and billing form. Must be submitted within 72 hours of admission for Medicaid clients. Form numbers and requirements vary by state.

Enrollment in the Program of All-Inclusive Care for the Elderly. Provides comprehensive medical and social services for individuals age 55+ who qualify for nursing home level of care but can live safely in the community. Covers all Medicare and Medicaid services.

Federally mandated preadmission screening for all individuals entering Medicaid-certified nursing facilities to identify those with mental illness, intellectual disability, or related conditions who may need specialized services.

Comprehensive evaluation for individuals identified in Level 1 screening. Determines if nursing facility placement is appropriate and what specialized services are needed.

Documentation establishing the Community Spouse Resource Allowance (CSRA) and Monthly Maintenance Needs Allowance (MMNA) protecting the non-institutionalized spouse's assets and income.